Posters

Outcome Analysis of Pediatric Flatfoot Deformity Correction Utilizing Calcaneal Osteotomies
Shine John DPM, Joel Hix DPM, Brandon Child DPM, Mike Maskill DPM
Alan R. Catanzariti DPM, FACFAS, Robert W. Mendicino DPM, FACFAS
Division of Foot and Ankle Surgery - Department of Surgery - The Western Pennsylvania Hospital - Pittsburgh, PA

Abstract

The flexible flatfoot is a common condition observed in the pediatric patient population. Symptoms may or may not be present in these patients. Those patients that have associated symptoms and fail conservative therapy may require surgical correction of the deformity. Osteotomies such as an anterior calcaneal osteotomy (Evans) and posterior calcaneal displacement osteotomy (PCDO) have been utilized to achieve correction. These procedures, when utilized alone or in combination, are effective in establishing structural realignment and improved function while preserving function of the hindfoot joints.  These procedures have been described in the literature with few clinical outcomes reported when utilized to treat the symptomatic pediatric flexible flatfoot.

Materials and Methods

We retrospectively reviewed patients between the ages of 7-17 who had surgical correction of a painful flatfoot. A single or double calcaneal osteotomy was performed on every patient. Allograft bone was used in all patients. We analyzed data ranging from 12 - 36 months follow-up. Charts and radiographs of patients who met the above criteria over the past 5 years were evaluated. Each chart was reviewed to obtain associated procedures (posterior muscle group lengthening) performed in conjunction with the calcaneal osteotomy as well as any complications. Radiographs were examined to compare and measure pre- and post-operative alignment. The data obtained from the chart and radiographs were recorded on a data collection sheet. Each data collection sheet was labeled numerically as a way to organize data collection. No patient identifiers were used. Clinical outcomes will be assessed by a modified AOFAS ankle-hindfoot questionnaire consisting of 5 questions. The survey was labeled with a number which corresponded to a data collection sheet. The survey was sent and completed by a parent or guardian. Failure to respond to the questionnaire was interpreted as a refusal to participate in the study and corresponding chart data was not used in this study. Data from returned surveys was transferred to the corresponding data collection sheet and analyzed. No patients were asked to return for a follow-up appointment.

Cases

11 year old girl with a painful flatfoot corrected with a PCDO and lateral column lengthening. There is noted improvement of the lateral radiograph. The sagittal talar 1st metatarsal angle improved 32 degrees. The calcaneal inclination improved 13 degrees. 11 year old boy underwent a lateral column lengthening and PCDO which resulted in a 26 degree improvement of the talar-1st metatarsal angle on the AP radiograph. The calcanealcuboid abduction was also completely aligned. 17 year old girl with severe pes planovalgus treated with a lateral column lengthening and PCDO. The AP talar-1st metatarsal angle improved 13 degrees and the sagittal talar-1st metatarsal angle improved 22 degrees.

Satisfaction Survey N=10

Results

Discussion

Calcaneal osteotomies are useful procedures to correct pes planovalgus of multiple etiologies. The purpose of our investigation was to evaluate the effectiveness of calcaneal osteotomies in the treatment of idiopathic pes planovalgus. Non-operative therapy is successful in most children with a flexible painful flatfoot, however, in children where symptoms persist surgery is indicated.

Many procedures have been described for the treatment of flexible pes planovalgus. These procedures include medial and lateral column osteotomies, arthroeresis, soft tissue tendon balancing, joint arthrodesis and a combination of these procedures. Only a few studies have evaluated the use of calcaneal osteotomies to treat symptomatic pes planovalgus. The ability to realign the foot with joint preservation makes this procedure very attractive. Lateral column lengthening corrects deformity in three planes including hindfoot valgus, forefoot abduction and midfoot pronation. The arch is recreated as the lateral foot lengthens around a fixed plantar fascia which elevates the arch as seen in the Jack toe-raise test.

Surgical indications for the procedure are not clear due to the lack of literature on the subject. Evans originally performed the procedure on 56 feet, 18 of which had idiopathic flatfeet, all of which had successful outcomes. Phillips reported outcomes of 15 feet which had idiopathic flatfeet and reported greater than 74% satisfaction. Anderson reported 89% satisfaction in his patients with idiopathic flexible flatfeet. Mosca reported satisfactory clinical and radiographic correction in all but 2 severely deformed feet. A medial cuneiform opening wedge osteotomy was performed in patients with skewfoot , otherwise no medial column procedure was performed. Neuromuscular disorders were present in 16 of 31 feet. These reports do not outline criteria for procedure selection nor do they report on combined calcaneal osteotomies for the correction of pes planovalgus. To the authors knowledge, this is the first study to report outcomes of a double calcaneal osteotomy for flatfoot correction in juvenile patients.

Yoo et al in a study of lateral column lengthening in children with cerebral palsy found that there is significant risk of unsatisfactory clinical results when the lateral talo-first metatarsal angle was greater than 25 degrees and a calcaneal pitch less than 5 degrees. Six feet in five patients in our study had a lateral talo-first metatarsal angle greater than 25. Satisfaction surveys were received from three of five patients and 4 of 5 feet as one patient had bilateral reconstructions. All 3 respondants expressed pain-free, unlimited activity. All 3 patients would recommend the surgical procedure to other children. There were no complications in any of these patients.

Our findings suggest that even in the absence of complete deformity correction clinical satisfaction can be attained. It has yet to be shown from this and other studies if radiographic parameters correlate with symptomatic improvement.

Overcorrection was seen in 5 patients. Unfortunately, only one of the five patients responded to the survey and reported optimal results in every category.

Calcaneal osteotomies are an effective way to improve structural and functional outcomes in the pediatric flatfoot and can prevent the necessity of medial column procedures and arthrodesis. In the authors experience the medial column sag seen on preoperative radiographs improves with calcaneal osteotomies in flexible deformities. This sag is believed to be compensatory dorsiflexion and when the equinus and deformity is corrected, this finding resolves. Average angular correction at the last follow-up appointment can be seen in Table 1.

References

1. Anderson, AF; Fowler, SB: Anterior calcaneal osteotomy for symptomatic juvenile pes planus. Foot Ankle 4:274-283, 1984.
2. Andreacchio, A; Orellano, CA; Miller, F; Bowmen, TR: Lateral column lengthening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy. J Pediatr Orthop 20:501-505, 2000.
3. Evans, D: Calcaneo-valgus deformity. J. Bone Joint Surg. 57-B:270-278, 1975.
4. Sangeorzan, BJ; Mosca V; Hansen, S: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot and forefoot. Foot Ankle 14:136-141, 1993.
5. Cohen-Sobel, E; Giorgini, R; Velez, Z: Combined technique for surgical correction of pediatric severe flexible flatfoot. J. Foot Ankle Surg. 34:183-193, 1995.
6. Mosca, VS: Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot. J. Bone Joint Surg. 77-A:500-512, 1995.

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